Psychology Case Study Autism

Abstract

Objective To assess the effectiveness of a manualized multi-component behavioral sleep intervention for children with autism spectrum disorder (ASD) and primary insomnia. Methods Three children (2 males and 1 female, aged 8–9 years) participated. The intervention consisted of a treatment handbook for parents; a distance treatment approach was used in which parents had weekly telephone contact with a therapist. The main behavioral strategies employed were Faded Bedtime with Response Cost and positive reinforcement. Within a case-series design, both subjective (parent-report questionnaires and sleep diaries) and objective (actigraphy) measures were used to record changes in children’s sleep and daytime behavior. Results For all 3 children, mean sleep onset latency was reduced following the intervention. These improvements were generally maintained at follow-up 12 weeks later. Conclusions The current study provides preliminary evidence for the effectiveness of a manualized behavioral sleep intervention program for improving insomnia in children with ASD.

autism spectrum, disorder, intervention outcome, sleep

Introduction

A growing body of research indicates significant sleep problems for many children with autism spectrum disorder (ASD), which is characterized by impairments in social interaction and communication skills and restricted patterns of behavior, interests, and activities (American Psychiatric Association [APA], 2000). Sleep problems documented in children with ASD include abnormal sleep–wake patterns, problems with sleep onset, early morning waking, poor sleep quality, shortened night sleep, night waking, and developmentally inappropriate co-sleeping (Richdale & Schreck, 2009). According to several studies (e.g., Paavonen et al., 2008), dyssomnias (disorders of initiating or maintaining sleep) occur significantly more often in children with ASD versus typically developing (TD) children. Indeed, most children with ASD appear to have sleep problems (Mayes & Calhoun, 2009).

In TD children, sleep problems are linked to daytime behavior problems, as well as attentional and other neuropsychological impairments (Sadeh, 2007). Objective measures of children’s sleep problems are also related to overall family stress (e.g., Sadeh, Raviv, & Gruber, 2000). A few studies have investigated the relationship between sleep problems and daytime child and family functioning in children with ASD. Among parents of children with ASD, those whose children have sleep problems experience higher levels of parenting stress (Doo & Wing, 2006). Studies also indicate that reduced child sleep also predicts higher autism symptom scores (Schreck, Mulick, & Smith, 2004).

Behavioral treatments for child sleep problems are more efficacious than medication in both the short and long term (e.g., Ramchandani, Wiggs, Webb, & Stores, 2000). According to a systematic review, behavioral treatments improve bedtime problems and night waking in TD children (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). Of the 52 intervention studies reviewed, 94% demonstrated that treatment was efficacious and more than 80% of children improved. Evidence was strong for unmodified extinction (systematic ignoring of bedtime disruption and/or night waking) and preventive parent education (promoting positive sleep habits). Some support was found for other procedures: graduated extinction, scheduled awakenings, and bedtime fading/positive bedtime routines. Kuhn and Elliot (2003) considered bedtime fading (consistent bedtime and wake-time routines, adjustment of bedtime to when the child is likely to fall asleep quickly and then slowly moving the bedtime earlier) to be the most promising alternative to extinction-based procedures, which have drawbacks such as lack of acceptability to parents.

Behavioral interventions for sleep problems in children with developmental disorders such as ASD have received little empirical attention. Piazza, Fisher and Sherer (1997) compared faded bedtime to bedtime scheduling in two groups of children with developmental disabilities (3 of n = 14 had ASD); faded bedtime improved sleep more. In this and five other studies of behavioral treatments for sleep problems in children with autism (mainly single-case studies, all with n<6), none of the treatments could be classified as well-established or probably efficacious (Schreck, 2001, using the criteria of Chambless & Hollon, 1998).

Since Schreck’s (2001) review, a handful of other case or multiple baseline studies on behavioral treatment strategies for children’s dyssomnias have included some children with ASD. For example, Weiskop, Richdale and Matthews (2005) treated 13 children (six with ASD and seven with fragile X syndrome) using parent training, positive bedtime routines, and extinction, and found improved settling, night waking and co-sleeping. Montgomery, Stores and Wiggs (2004) found that a parent handbook was as effective as traditional face-to-face treatment for sleep problems in 66 children with severe learning disabilities (21 with ASD). All of these studies are limited by heterogeneous samples (range of ASD and other diagnoses) and lack of diagnostic information. In addition, these studies relied on observational and parent report measures, and lacked an objective measure of sleep (e.g., actigraphy). In one recent study, Reed et al. (2009) demonstrated positive impact of parent education groups on the sleep and daytime behavior of 20 children with ASD using actigraphy in addition to parent report. However, more research is needed regarding the effectiveness of promising behavioral strategies for sleep problems in children with ASD.

The current study examined the effectiveness of a manualized multi-component behavioral sleep intervention program. This program, shown to be effective for treating sleep onset difficulties in children with Attention Deficit/Hyperactivity Disorder (ADHD; Mullane & Corkum, 2006), was tailored for children with ASD. It was delivered using a distance treatment approach (i.e., by telephone) to minimize burden on parents. The program combined a parent handbook with weekly telephone contact with a trained therapist (PhD student in Clinical Psychology). The primary objective was to reduce sleep onset latency (the time it takes to fall asleep after “lights out”) in children with ASD. Potential secondary benefits included increasing the children’s sleep efficiency and sleep duration, and improving their daytime behavior. In a case-series design, both subjective (parent questionnaires and sleep diaries) and objective (actigraphy) measures were used to track children’s sleep and daytime behavior.

Method

Participants

Children previously diagnosed with ASD between 5 and 9 years old were recruited for the study from the autism service at a pediatric hospital, as well as from community sources. Children were eligible if they met DSM-IV criteria for primary insomnia (APA, 2000), were attending school and were cognitively able to benefit from the intervention. This age group was selected in order to ensure that the children would be young enough to require direct parental involvement in their bedtime routines and sleep habits.

Children with neurological disorders (e.g., epilepsy), were excluded, as were children who were not toilet trained, had nocturnal enuresis, or co-slept with their parents. Children who had received a behaviorally based sleep intervention in the past 6 months, and children who were currently receiving psychopharmacological interventions for sleep problems, or whose type and dose of other psychoactive medication might change during the study, were also excluded.

Nine potential participants were screened; four were ineligible (one each: not toilet trained, nocturnal enuresis, co-slept with parents, and no sleep onset problems). One additional child was excluded because parents were concerned that he would resist actigraphy recording. Thus, four children (three males) were enrolled. Of these, one child’s parents did not complete end-of-treatment or follow-up measures. All three children who completed the study had been diagnosed with ASD by the same clinical psychologist, using DSM-IV criteria based on the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore & Risi, 1999), Autism Diagnostic Interview – Revised (ADI-R; Lord, Rutter & Le Couteur, 1994), and clinical judgment. Each child had significant difficulty initiating sleep and met DSM-IV criteria for primary insomnia (APA, 2000), and scored above the cut-off of 41 on the total sleep disturbances subscale of the Child Sleep History Questionnaire (CSHQ; Owens, Spirito, & McGuinn, 2000).

The participants were one girl, “Laurie,” (9 years, 3 months; Wechsler Full Scale IQ = 93), and two boys, “Sam” (9 years, 4 months; IQ = 128), and “Richard,” (8 years, 3 months; IQ = 92). All three children met both ADOS and ADI-R criteria for autism, except Richard, whose ADI-R repetitive and restricted behavior score fell 1 point below cutoff. All were Caucasian and from two-parent, multi-child households. All parents were reportedly involved in implementing the intervention, but mothers took all telephone calls from the therapist. During the study period, Laurie took no medication; both boys took previously prescribed consistent doses of stimulant medication (Sam: 30 mg/day Ritalin; Richard: 36 mg/day Concerta). The primary sleep problem for all three children was prolonged sleep onset latency. By parent report, Laurie required approximately 1 hr, Sam took between 0.5 and 1 hr, and Richard took 2 hr to fall asleep.

Materials

All measures were collected for 1 week during baseline, end-of-treatment (7 weeks for Richard, 8 weeks for Sam, and 9 weeks for Laurie) and follow-up (12 weeks after end-of-treatment), unless otherwise indicated.

Actigraphs

Actigraphs provide reliable and stable sleep recordings in school-aged children (e.g., Sadeh et al., 2000) and have high agreement with polysomnography (85–90%). Actigraphy has the advantage of being less intrusive and more feasible than polysomnography, especially with special populations such as children with ASD. Mini-Motionlogger actigraphs were worn on the child’s non-dominant wrist from the time the child got into bed until he/she got out of bed in the morning. Actigraph recordings were scored using software based on a validated sleep algorithm (Sadeh, 1994). Children’s initial bedtimes were manually entered into the program based on information recorded each night by parents in the child’s sleep diary.

Sleep Diaries

Parents recorded, on a nightly basis, detailed information about their children’s sleep onset latency and sleep duration. The diaries were developed by Mullane and Corkum (2006) for a study of a comparable sleep intervention for children with ADHD.

Children’s Sleep Habits Questionnaire

The Children’s Sleep Habits Questionnaire (Owens et al., 2000) is a widely used parent-report questionnaire that measures sleep problems in preschool and school-aged children. Higher CSHQ scores indicate more disturbed sleep. The CSHQ possesses adequate psychometric properties and differentiates between clinical samples of children with sleep problems and community samples of children without sleep problems (Owens et al., 2000).

Child Behaviour Checklist

This measure assesses social competence and a wide range of behavior and emotional problems in children and adolescents aged 6–18 years. The Child Behaviour Checklist (CBCL) has adequate reliability and validity (Achenbach, 1991).

Parent Satisfaction Questionnaire

This author-developed measure was administered to parents by telephone following end-of-treatment. It was designed to assess parents’ satisfaction with the intervention program.

Better Nights, Better Days: Treatment for Sleep Difficulties Parent Handbook

This multi-component program has been shown to decrease the severity of dyssomnias in a small group of children with ADHD (Corkum, Mullane, & Moon, 2006a; Mullane & Corkum, 2006). The first of the five handbook chapters provided information about basic sleep physiology and sleep problems. The second chapter outlined principles of sleep hygiene and the importance of consistent bedtime routines. The third chapter introduced the two main behavioral strategies employed in the program: Faded Bedtime with Response Cost (FBRC) and positive reinforcement. The fourth chapter helped parents tailor these two behavioral strategies to their child. The final chapter provided instructions on how to fade these two behavioral strategies. For a more detailed description, please contact the corresponding author.

The first step in the FBRC strategy was to establish a consistent wake time and a new bedtime 30 min later than the time that the child typically fell asleep. If the child did not fall asleep within 20 min of the new bedtime, he/she was removed from bed and made to engage in a low intensity activity (e.g., reading) for 20 min. Removal from bed was the response cost component of the intervention. After 20 min, the child was returned to bed and the procedure was repeated until the child fell asleep within 20 min. Once the child was able to fall asleep within 20 min of the new bedtime for two consecutive nights, bedtime was moved 20 min earlier. This process was repeated until the child reached his/her target bedtime. The positive reinforcement strategy consisted of a sticker chart with rewards for positive sleep behaviors, such as following the bedtime routine without resistance.

Procedure

Approval for this study was obtained from the Research Ethics Board at a tertiary pediatric hospital. Each family was enrolled and began the study as they were recruited (i.e., not concurrently). Interested parents completed a telephone screening to determine their child’s eligibility. Parents then met the therapist, provided consent to participate, and completed the baseline CSHQ and CBCL. For the baseline week, parents completed sleep diaries and the children wore actigraphs. For each of the five subsequent weeks, parents read one chapter in the treatment handbook and completed the associated exercises. At the end of each week, the therapist contacted the parents by telephone to review the content of the chapter and monitor progress with the exercises. The therapist followed a standardized protocol designed to complement the parent handbook (Corkum, Mullane, & Moon, 2006b).

Although the intervention program was designed to run for only 5 weeks, child illnesses and challenges implementing the FBRC strategy lengthened the program to 7 weeks for Richard, 8 weeks for Sam, and 9 weeks for Laurie. In all cases, weekly phone calls with the therapist continued and focused on trouble-shooting around the FBRC strategy. In the week following the end of the program (end-of-treatment), parents completed the CSHQ and CBCL, and the children wore actigraphs. Twelve weeks following the end of the program, parents again completed the CSHQ, CBCL, and sleep diaries, and the children wore actigraphs for a week (follow-up).

Results

In keeping with the case-series design, data from the three children were examined individually. Trends and patterns are outlined below.

Sleep Onset Latency

Mean sleep onset latency decreased after treatment for all three children, as measured by actigraphy (see Table I). For Laurie, actigraphy indicated a decrease of 23 min from baseline to end-of-treatment. At follow-up, her mean sleep onset latency remained improved. Sam’s mean sleep onset latency decreased by 9 min and decreased by another 2 min at follow-up. For Richard, mean sleep onset latency decreased by 24 min, and was maintained at follow-up.

Table I.

Sleep Variables (Actigraphy, CSHQ, and Sleep Diary) and Daytime Behavior Problems (CBCL)

Laurie
Sam
Richard
Dependent Variable BL EOT FW-U BL EOT FW-U BL EOT FW-U 
Sleep variables 
Actigraphy 
    Sleep onset latency (mean min, SD67.71 (26.04) 44.86 (28.09) 48.00 (20.73) 33.71 (16.56) 24.43 (12.97) 22.14 (10.96) 74.00 (20.24) 49.86 (24.86) 52.29 (63.37) 
    Sleep duration (mean min, SD)538. 00 (41.16) 554.43 (40.43) 523.86 (10.61) 554.43 (29.44) 545.57 (19.46) 554.86 (27.10) 538.57 (18.26) 535.86 (18.33) 525.71 (51.91) 
    Sleep efficiency (%) 97.19 96.35 97.99 87.91 92.13 85.15 93.09 89.07 82.49 
CSHQ Subscale Raw Scores 
    Sleep onset delay (range:1–3) 
    Sleep duration (range: 3–9) 
Sleep diary 
    Sleep onset latency (mean min, SD50.00 (20.00) 47.86 (29.56) 26.43 (15.20) 37.14 (10.07) 29.29 (15.39) 16.29 (8.50) 76.00 (30.23) 31.14 (30.61) 23.00 (10.85) 
    Sleep duration (mean min, SD553.57 (29.82) 552.57 (39.67) 545.71 (20.50) 555.29 (26.56) 532.86 (31.87) 562.86 (23.78) 540.71 (22.25) 565.71 (37.13) 562.86 (45.36) 
    Bedtime (p.m.) 9:21 9:36 9:51 9:30 9:49 9:56 9:09 9:26 9:36 
    Wake time (a.m.) 7:28 7:36 7:19 7:30 7:17 7:34 7:28 7:24 7:24 
Daytime behavior problems 
    CBCL Total Problems Score (T-score) 61 57 57 75 73 71 61 53 49 
    Score range Borderline Average Average Clinical Clinical Clinical Borderline Average Average 
Laurie
Sam
Richard
Dependent Variable BL EOT FW-U BL EOT FW-U BL EOT FW-U 
Sleep variables 
Actigraphy 
    Sleep onset latency (mean min, SD67.71 (26.04) 44.86 (28.09) 48.00 (20.73) 33.71 (16.56) 24.43 (12.97) 22.14 (10.96) 74.00 (20.24) 49.86 (24.86) 52.29 (63.37) 
    Sleep duration (mean min, SD)538. 00 (41.16) 554.43 (40.43) 523.86 (10.61) 554.43 (29.44) 545.57 (19.46) 554.86 (27.10) 538.57 (18.26) 535.86 (18.33) 525.71 (51.91) 
    Sleep efficiency (%) 97.19 96.35 97.99 87.91 92.13 85.15 93.09 89.07 82.49 
CSHQ Subscale Raw Scores 
    Sleep onset delay (range:1–3) 
    Sleep duration (range: 3–9) 
Sleep diary 
    Sleep onset latency (mean min, SD50.00 (20.00) 47.86 (29.56) 26.43 (15.20) 37.14 (10.07) 29.29 (15.39) 16.29 (8.50) 76.00 (30.23) 31.14 (30.61) 23.00 (10.85) 
    Sleep duration (mean min, SD553.57 (29.82) 552.57 (39.67) 545.71 (20.50) 555.29 (26.56) 532.86 (31.87) 562.86 (23.78) 540.71 (22.25) 565.71 (37.13) 562.86 (45.36) 
    Bedtime (p.m.) 9:21 9:36 9:51 9:30 9:49 9:56 9:09 9:26 9:36 
    Wake time (a.m.) 7:28 7:36 7:19 7:30 7:17 7:34 7:28 7:24 7:24 
Daytime behavior problems 
    CBCL Total Problems Score (T-score) 61 57 57 75 73 71 61 53 49 
    Score range Borderline Average Average Clinical Clinical Clinical Borderline Average Average 

View Large

Inspection of night-by-night sleep onset latency as measured by actigraphy revealed an overall reduction in sleep onset latency at end-of-treatment compared to baseline for all three children (see Figure 1). For Laurie and Sam, this reduction in night-by-night sleep onset latency was maintained at follow-up. Richard’s night-by-night sleep onset latency varied widely at follow-up. Of note, variability in night-by-night sleep onset latency appeared to increase following treatment for all three children.

Figure 1.

Night-by-night sleep onset latency (as measured by actigraphy) for Laurie (A), Sam (B), and Richard (C).

Figure 1.

Night-by-night sleep onset latency (as measured by actigraphy) for Laurie (A), Sam (B), and Richard (C).

Sleep diaries also indicated a decrease in mean sleep onset latency for all three children from baseline to end-of-treatment, with decreases maintained at follow-up (see Table I). Sleep onset latency as measured by the mean CSHQ Sleep Onset Delay subscale decreased for both Sam and Richard but was unchanged for Laurie (see Table I).

Sleep Duration

At end-of-treatment, no systematic changes were observed in the children’s mean sleep duration by actigraphy, sleep diary or CSHQ (see Table I). Based on actigraphy data at follow-up, the children’s average sleep duration per night either decreased slightly from baseline (Laurie and Richard) or remained the same (Sam). Interestingly, sleep diary and CSHQ data suggested increased sleep duration for Richard and Sam from baseline to follow-up.

Sleep Efficiency

There was no clear pattern of change in mean sleep efficiency (i.e., percentage of time asleep compared to time in bed) as measured by actigraphy (see Table I). Laurie’s sleep efficiency was high (over 96%) and remained stable across recording weeks. Sam’s sleep efficiency increased after treatment, but this was not maintained at follow-up. Surprisingly, Richard’s mean sleep efficiency decreased slightly after treatment and further decreased at follow-up.

Daytime Behavior

All three children showed small decreases in total (internalizing and externalizing) daytime behavior problems, as measured by CBCL scores (see Table I). For Laurie and Richard, Total Problems T-scores decreased from the borderline clinical range at baseline to the average range at end-of-treatment, and remained in the average range at follow-up. Sam’s Total Problems T-score decreased slightly from baseline to end-of-treatment and again at follow-up, but remained in the clinical range.

Parent Satisfaction

Parents provided ratings on a brief author-created satisfaction survey. Ratings were given on a 5-point scale (ranging from 0 = strongly disagree to 4 = strongly agree). Parents were satisfied with the sleep intervention (mean rating = 3.0) and indicated that they would encourage other families to participate in this intervention (mean rating = 3.67). Parents also found the program manual helpful (mean rating = 3.67).

Discussion

This study examined the effectiveness of a multi-component manualized behavioral sleep intervention program tailored for children with ASD. This program consisted of a parent handbook (Better Nights, Better Days: Treatment of Sleep Difficulties Parent Handbook) and weekly phone contact with a therapist. The effectiveness of this program was studied for three children with ASD and primary insomnia using a case-series design. The results add to the limited literature on the effectiveness of behavioral strategies for treating sleep problems in children with ASD. The current findings provide some evidence for the effectiveness of this treatment program for reducing sleep onset latency and improving daytime behavior in these children. For all three participants, mean sleep onset latency decreased following the intervention according to both actigraphy and sleep diary. These improvements were relatively small but were maintained at 12-week follow-up. Night-by-night sleep onset latency actigraphy data generally echoed the summary data; it showed a decrease in sleep onset latency for all three children following treatment. This decrease was maintained at follow-up for two children. The third child’s sleep onset latency varied widely during the follow-up week, but the sleep diary contained no explanation that would account for this (e.g., sickness, change in routine). Overall, variability in night-by-night sleep onset latency appeared higher in all three children during the end-of-treatment and follow-up weeks than during the baseline week. This pattern may indicate that for these children, prolonged sleep onset latency is the natural state or set point. The variability at end-of-treatment and follow-up may reflect families’ ongoing efforts to implement the treatment strategies they learned in order to adjust this set point.

Contrary to predictions, actigraphy data showed that average sleep duration decreased slightly for two of the three children from baseline to follow-up, but was stable for the third child. One possible explanation is that as part of the faded bedtime strategy, the children were put to bed later (in order to decrease time awake in bed; see Table I). This had a positive impact on sleep onset latency but the trade-off may have been slightly decreased sleep duration for two of the three children.

In terms of daytime behavior, total behavior problems decreased from the borderline range of severity at baseline to the average range at end-of-treatment for two of the three children, and these improvements were maintained at follow-up. The third child’s total behavior problems decreased yet remained in the clinical range. Thus, small changes in the expected direction were observed in parent-reported behavior problems. It is noteworthy that daytime behavior appeared to improve following treatment despite no increase in the children’s sleep duration or improvement in sleep efficiency. Parents’ adoption of more structured bedtime strategies and anecdotal reports of decreased bedtime conflict might help to account for this effect.

Several limitations apply to the results of this study. First, as with all case study designs, there was no control group. A multiple baseline design was considered; however, the burden of completing questionnaires and daily sleep diaries, as well as ensuring that the children wore the actigraph each night, was judged too heavy for this group of parents. Therefore, outcome data were collected during single weeks at baseline, end-of-treatment and follow-up. A second limitation is that the results may not be generalizable to a wider population of children with ASD and primary insomnia. Further research is needed to determine whether older and/or younger children with ASD and those with below-average cognitive ability might benefit from such an intervention program. A third limitation is that the program was designed for 5 weeks but all three families of children with ASD needed at least two extra weeks to implement the treatment components. Although the length of treatment did not appear to have any systematic effect on outcome, it is important to consider that both the family’s implementation time and the total phone contact time with the therapist varied across cases.

Implementing behavioral strategies for child sleep problems is challenging for all families; however, a number of obstacles are specific to children with ASD. Finding effective rewards for the positive reinforcement component of the program was a challenge. One modification was that stickers earned for positive sleep behaviors were “cashed in” more quickly than for children with ADHD (Mullane & Corkum, 2006), in order to maintain motivation. It was also difficult to identify appropriate quiet activities in which the children with ASD could take part when they were removed from bed during the FBRC procedure. Participants required a lot of parental supervision during such activities, and often their preferred quiet activities were related to their special interests or preoccupations. These children often resisted the interruption of these activities when they were returned to bed.

In conclusion, the current study provides preliminary evidence for the effectiveness of a multi-component manualized behavioral sleep intervention program for improving insomnia in high-functioning children with ASD. Importantly, however, the study also highlights the unique challenges of treating sleep problems in children with ASD. Further large-scale research employing an experimental design is needed in order to determine the program’s clinical utility.

Funding

E. C. Moon is supported by doctoral awards from the Social Sciences and Humanities Research Council of Canada (SSHRC) and the Nova Scotia Health Research Foundation (NSHRF).

Conflicts of interest: none declared.

Acknowledgments

We gratefully acknowledge the hard work and dedication of the families who took part in this study. We also thank the clinicians who assisted with study recruitment and data collection.

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D.T.
Male, Age 10
Autism, seizure disorder


D.T. was verbal with limited language skills. He could sing in complete sentences (echolalic) but communicated using one or two word phrases. He communicated mostly by pointing. When he did speak, his enunciation was poor except when he was angry at which time the word would be clear. He displayed self-stimulatory behavior in the form of rocking, hand-turning, and hand flapping. His gross motor skills were below normal and he wore leg braces. His fine motor skills were poor and he was unable to tie his shoes. His sleep was good but he was defiant and unable to calm down at bedtime. He showed no interest in other children and his eye contact was poor. His seizures had begun at age two. He was taking medications for seizures and experienced one every ten to fourteen days.

After five weeks with REI, his mother reported that he was showing more caring towards others and his eye contact improved significantly. He began imitating other children (speech and facial expressions) and exhibited more interactive play with others. He was noticeably more calm and had fewer tantrums. His speech therapist noticed that he was able to talk clearer and that he began using 2-3 word phrases. His attention span improved and he was more able to stay with the lessons. He listened to the recording at bedtime and showed an improved ability to calm himself down and make the transition to sleep. He would often fall asleep half way through second side of tape.

After twelve weeks D.T. continued listening to the REI Program rhythms at bedtime and he would insist on listening to it while going to sleep. His school teacher and principal noticed improvements in his language skills, responsiveness, memory, and his level of understanding. They enrolled him in a regular classroom for the coming school year. He had not had any seizures for the previous four weeks. His doctor began to taking him off his medication. His language skills and vocabulary continued to improve, along with his social skills.


D.N.
Female, Age 6
Autism


D.N. was verbal with limited language skills. She used simple sentences and would only speak to voice demands. She was non-aggressive and she would tantrum frequently and often demand attention. She displayed considerable self stimulatory behaviors, which included biting herself, hitting her legs, tongue-twisting, and hand-clenching. Her fine motor skills were poor--she grasped with her palm. Her gross motor skills were good, however her balance was not as good. She had good eye contact and was very affectionate towards family. Her social skills were poor--she would engage in some parallel play if directed to do so but would not seek out other children.

Ten weeks after beginning the REI Program D.N. showed considerable progress. She demonstrated more interest and awareness of her surroundings and began approaching other children and initiating interactions with them. She was much more interested in doing things and interacting, and she seemed to want to do what others were doing in school. She began speaking more--her vocabulary and enunciation both greatly improved. Her garegiver described that she would often engage in self talk while the REI rhythms were being played and it seemed that she was working on her speach skills during this time. Her balance also improved. Her mother reported that she was much more relaxed overall and was much more pleasant to be around--she was tantrumming less and was much quicker to respond to requests. Her self-stimulatory behaviors dimished significantly except for hand-clenching.



C.P.
Male, Age 35
Autism


C.P. lived in a group home since age 14. He exhibited self-stimulatory vocalizations most of the time--very loud, fast and threatening. He was able to speak clearly with correct grammar, however he rarely communicated verbally with others. He was highly aggressive and violent-- generally had 3-4 incidents per week that were reported to the state. He would act out violently when asked to do anything for more than a few minutes. He was generally noncompliant, impatient, and characterized as lazy by the staff. He enjoyed riding horses but would hit them occasionally. His sleep was poor. He often woke throughout the night and tried to get out of facility. If not constantly watched, he would wander the neighborhood and enter nearby homes. He was obsessive about food and had poor table manners and he would eat as much food as he could very fast.

After one month with REI he was much less aggressive and the facility had no incident reports after the first week of the study. He would often request the tape at night. He began sleeping through the night starting second day and was no longer trying to get out. He still sometimes wandered during the day, but he stayed within the facilities boundaries. He was much more compliant and showed improved ability to listen. His self-stimulatory vocalizations continued, but he would stop when told to do so. He was starting to use conversational speech and would say 2-3 sentences when asked questions.

After eight weeks: still no incident reports, much less aggressive. He was still sleeping well and still showing improvements in compliance and listening ability. His self-stimulatory vocalizations decreased and he began initiating conversation with others.

ctory

Placebo-controlled case studies

The following case studies were conducted in a placebo-controlled format from March through May, 1995. Each of the subjects received a REI Program tape, although the subjects were unaware whether they had a real REI recording or a placebo tape containing traditional African rhythms. They were instructed to play the recording daily for the first four weeks and at least three times per week for the second four weeks. Assessments were made by the parents.

S.W.
Male, age 11
Autism


After four weeks of using the recording daily S.W.'s mother reported that He seems more cooperative, calm, focused, and makes less noises. He is also showing more social interaction at school. He has talked about friends and he is initiating play with others. He seems more comfortable with himself.

At the eight week assessment his mother reported, In general he has made less repetitive noises, has been calmer and more cooperative. He has become intensely interested in his LEGOs and been very creative. He used to have to chew gum all the time, now he has not asked for any in a long time. He has a check list for his morning routine and evening routine, and I feel that he is more cooperative and independent in following the routines since he has been using the REI tape--especially this last four weeks.



J. A.
Male, age 4
Autism


After four weeks in the study his mother reported that J.A.'s eye contact has improved a lot. Overall, he was much calmer, a lot less impulsive and interacted with others much more frequently. I asked his preschool teachers if they were doing anything different. They all said that they noticed a difference in J.A. but they hadn't changed their routine any. His occupational therapist also noticed that J.A. seemed calmer.

He's really trying to talk now when before he didn't seem to have any interest. He sometimes responds verbally now. He still has some unmeaningful hand movements, but he has had no panic attacks and is much less withdrawn. His autistic behavior has lessened so much that I think his main problem now is his lack of speech.


At the eight week assessment she stated, He is calmer, more receptive. Before he was listless and unresponsive much of the time. For the first time he seems to realize he's not separate from the rest of the world. His eye contact has improved dramatically. His tantrums are fewer and when he does have a tantrum, they are more like outbursts of emotions rather than anger and defiance. He hasn't had any panic attacks in the past two months.

After twelve weeks she reported, At the beginning of the study he didnít even seem to realize that speech has a purpose. He has gone from saying only one or two words a day at the beginning to about 30 or 40 a day now. His pronunciation has also improved. He now seems to realize that speech has a purpose, and he has been putting a lot of effort into talking.

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G.M.
Male, Age 4
Autism


After four weeks his mother reported that He's speaking more and more. He began saying his brother's name. He also showed significant improvements in social engagement, eye contact and verbal and non-verbal communication. His mother stated that He now can let us know 98% of the time what he wants.

After eight weeks his mother reported that he interacts more with other children and has begun turn taking also. G.M's eye contact also improved and he seemed to be expressing more emotions. She reported that It is as if now that he is more tuned in, he expresses verbally what he wants. He gets mad like a two year old when he doesn't get it.

After twelve weeks, unaware of the study, his teachers reported an improvment in his attention span, and social engagement. They also reported that he began making friends at preschool. He continued to show progress in language skills--his mother stated that He is now initiating conversation and initiating social interactions. She also reported that he liked the tape and would play the tape by himself.

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